Provider Demographics
NPI:1093054249
Name:WILSON, LICATA JEANE
Entity Type:Individual
Prefix:
First Name:LICATA
Middle Name:JEANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 DAVIS DR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2241
Practice Address - Country:US
Practice Address - Phone:417-256-2152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008023618224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant